Off the Beaten Path: How Nurse Practitioners Are Addressing Nature-Deficit Disorder

As the burden of comorbidities such as obesity, hypertension, and diabetes continues to rise,1 new alliances are forming to address prevalent health issues, both inside and outside the clinical setting.

During her time as a Duke-Johnson & Johnson Nurse Leadership Fellow, Georgetown University School of Nursing & Health Studies professor Lois Wessel, RN, FNP-BC, spent one year conducting research on the roles green spaces, activity in nature, built environments, and socio-cultural considerations play in chronic disease. The result of her research was an article titled, “Shifting Gears: Engaging Nurse Practitioners in Prescribing Time Outdoors,” which appears in the January 2017 issue of The Journal for Nurse Practitioners.2 In the article, Wessel’s research outlines the emergence of interprofessional collaboration models that Nurse Practitioners (NPs) can engage to integrate outside play as a regular part of a patient’s well-balanced routine.

One program Wessel describes is Park Rx*, the National Park Prescription Initiative that has teamed public land agencies with clinicians to promote outdoor recreation. Launched by pediatrician Robert Zarr, M.D.,  and endorsed by the U.S. Surgeon General and the National Park Service, Park Rx is “designed in collaboration with healthcare  providers and community partners that utilize parks, trails, and open space for the purpose of improving individual and community health,” which includes symptoms associated with “nature-deficit disorder,” a condition coined by Richard Louv in his book, Last Child in the Woods.3 As health promotion and disease prevention experts, Nurse Practitioners are encouraged by park initiatives to dispense prescriptions for nature therapy, with the goal of empowering patients to walk, bike, and play outdoors.

Medical prescriptions are often issued in response to an ailment or as a course for treatment, but with collaborative park programs, they are now also used as a tool to avert chronic disease, such as obesity, which often occurs due to insufficient exercise.

“My patients have numerous problems that often stem from inactivity—these include high blood pressure and weight problems,” says Wessel when asked about her research examining park initiatives. “Going outside can be a simple way to lift spirits, change moods, and entertain children. It’s free, healthy, and sorely needed by people who spend most of their day inside and plugged in. As a front-line clinician with patients experiencing both social and medical problems, I tell them to spend some time outdoors each day as part of an overall wellness plan.”

Speaking directly to the Georgetown University value of cura personalis, Wessel, a graduate of the school’s Family Nurse Practitioner program and an instructor there for more than 10 years, describes nature therapy as a family-friendly activity that “aligns with the NP model of holistic and comprehensive care of prevention, wellness, and the whole person—body and mind,”4 encompassing healthy lifestyle promotion.

In addition to writing prescriptions for outdoor recreation, Wessel’s research suggests other opportunities for NPs to integrate nature therapy into a patient’s plan of care. The use of electronic medical record (EMR) technology in clinics can, for instance, track “the number of park prescriptions given to patients” and allow NPs to “follow benchmarks of weight, body mass index, blood pressure, vitamin D level, and [glucose] and cholesterol levels … to determine whether time outdoors has made an impact on overall health and wellness.”5

Adding activity as a vital sign is another recommendation indicated by research, as it not only standardizes patient assessment and interviewing methods but also offers health care providers  “an opportunity to address lack of exercise and talk about local exercise and weight-loss programs.”6 Over time, such measures can go from being reactive in treatment to being proactive, as they prevent recurrence or onset of chronic disease.

Examining exposure to nature as a social determinant of health, Nurse Practitioners incorporate preventive measures, including education, into a holistic care plan to get children and families to unplug from their devices for a few minutes each day. The National Wildlife Federation, whose website offers tools to motivate children to explore wilderness, observes, “Our kids are out of shape, tuned out, and stressed out because they are missing something essential to their health and development: connection to the natural world.”7

One reason for the disconnect is that children’s free time, which was previously spent on playgrounds, is now occupied by computer games and online socializing. In her research, Wessel discovered that “more than seven hours per day are spent on all forms of e-media,” as opposed to “fewer than 30 minutes of outdoor time daily.”8 The result is increased rates of obesity and vitamin D deficiency, as well as behavioral issues stemming from attention deficit-hyperactivity disorder (ADHD).9

Beyond opportunities for physical activity, time spent outside also reaps unexpected cognitive enhancement, as published data shows simple proximity to, or even window views of, green spaces is associated with outcomes ranging from improved school performance to coping mechanisms.10 Stress stability is another perk, as parks provide respite from the seemingly endless demands of modernization and spiral of connectivity.

There are other documented advantages to immersion in organic environs, including reduced healing time and elevated immune system responses. Post-surgical patients in several studies were found to require fewer pain medications during recovery, and others displayed a greater resistance to infections after enjoying even “forest-like” surroundings.

The illustration below, created by Nursing@Georgetown, depicts more of the holistic and systemic benefits of outdoor recreation. It is available as a community resource, for download and printing. 

 

Read the text-only version.

Although prescribing recreational activity may be a new trend, nature therapy is an indigenous tradition that has existed in many societies for centuries. Native American, Latin, and Ayurvedic cultures have long extracted medicines from environmental resources for their health remedies, as other civilizations value being immersed in flora. Japanese Shinrin-yoku,11 Norwegian friluftsliv, Dutch uitwaaien, and German Waldeinsamkeit uniquely demonstrate a cultural recognition of the stabilization and stress relief experienced after socialization, bonding, and solitude in nature. By prescribing time outdoors, clinicians in the United States are now also using nature therapy to help their patients by connecting with recreation departments and community officials seeking to boost public health.

For NPs to make a difference though, Wessel says specific action items are key: “Broadly suggesting that patients exercise is something most patients already know and does not engage or support them in what they enjoy doing.” She continues, “Providers faced with the high rates of obesity and other chronic diseases may often focus on what not to do or eat instead of what is positive and possible.”12 However, numerous resources, including those listed below 13, are available to guide NPs interested in motivating children, their guardians, and teachers to get outside.

Resources and Patient Education for Prescribing Time Outdoors

National Environmental Education FoundationThis foundation provides a Park Rx training module and prescription forms for outdoor activity, available for download in English and Spanish.

DC Park Rx: This community health clinic initiative tailors outdoor activities based on interests and locations of patients.

National Park Service: “Healthy Parks Healthy People” is a global movement that harnesses the power of parks and public lands to contribute to a healthy civil society.

National Wildlife Federation: This website resource includes tools on how to encourage children to engage in outdoor activity and play. 

Let’s Move!: Established by first lady Michelle Obama, this initiative aims to alleviate the epidemic of childhood obesity. Worksheets for children are available.

Step It Up!: This program includes Surgeon General Vivek Murthy’s campaign to increase walking and walkable communities. 

Safe Routes to School: Led by parents, schools, community leaders, and local, state, and federal governments, this program works to mobilize families to walk and bike to school.

Beyond health care implementation, organizational and civic frameworks also play a part in the rise of symptoms associated with nature-deficit disorder, as “the built environment and the areas where people play, work, and live are directly related to how much time people spend outdoors,” Wessel writes.14 In this way, NPs can advocate for unexpected sources of exercise, including neighborhood “sidewalks, lighting in parks, improved park maintenance, and neighborhood safety to strengthen local interest in being outside.”15

In her article, Wessel goes on to explain how “the quality of parks, as indicated by lighting, benches for rest, bathrooms, trail maintenance, cleanliness, and attention to plants and playground infrastructure, may influence usage.”16 Because NPs working in and around schools often serve as primary care providers for students, they can “start to engage with school systems for local cost improvements, such as night-time lighting and keeping school playgrounds open during evenings and weekends.”17

With the goal of disease prevention, NPs are ideally positioned to collaborate with organizers in their communities, ranging from recreational facilities staff and park rangers, to transportation planners and public health activists. Thanks in part to park prescriptions, NPs have a new way to encourage neighborhood families and patients to enjoy the therapeutic benefits of nature.18

And, as Surgeon General Murthy notes, “the refills are unlimited.”19

 

*Nursing@Georgetown and Lois Wessel are not employees of or affiliated with Parks Rx. For more information on that initiative, please contact Park Rx directly

 

Sources

1. Anderson, G., Horvath, J. “The Growing Burden of Chronic Disease in America,” Public Health Reports, 2016. Pages 263-270. Accessed Feb 24, 2017. http://journals.sagepub.com/doi/abs/10.1016/j.phr.2004.04.005?journalCode=phrg

2. Material reprinted from The Journal for Nurse Practitioners, Vol. 13 No. 1, Ms. Lois A. Wessel, “Shifting Gears: Engaging Nurse Practitioners in Prescribing Time Outdoors,” Pages 89-96, January 2017, with permission from Elsevier.

3. Louv, R. “Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder,” Algonquin Books, 2005.

4.Wessel, 93.

5.Wessel, 94.

6. Wessel, 94.

7. Wessel, 89-90. Research cited: National Wildlife Federation. Health benefits. Updated 2016. Accessed Feb 24, 2017. www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Health-Benefits.aspx

8. Wessel, 90.

9. Wessel, 89-91.

10. Wessel, 90.

11. Wessel, 90.

12. Wessel, 93.

13. Wessel, 92.

14. Wessel, 92.

15. Wessel, 92.

16. Wessel, 93. Research cited: Moore, L.V., Diez Roux, A.V., Evenson, K.R., McGinn, A.P., Brines, S.J. “Availability of Recreational Resources in Minority and Low Socioeconomic Status Areas,” American Journal of Preventive Medicine, 2008. Pages 16-22.

17. Wessel, 95.

18. Wessel, 96.

19. Wessel, 94.

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